Analyse requirements, co-design solutions with users

Right Decision Service implementation guide

The aim of requirements analysis is to ensure that the decision support tool you develop accurately reflects your stakeholders’ needs and requirements. This process should ensure that all stakeholders and the development team have a shared understanding of the vision for your decision support tool, and of how it will look and work.

Osheroff’s '5 Rights' framework [Osheroff 2012] is a useful reference point for this stage. This states that good decision support requires the delivery of:

The right information (eg. a risk score or advice on what to do next)
In the right format (eg. as a short message that is readable on a screen)
To the right person (eg. a care professional, their manager, or to the patient/service user)
At the right time (eg. before, during or after consultation)
Through the right channel (eg. as an app, integrated with the record system, or in an email or as a text message to their phone)

Key steps in the requirements analysis process include:

Step 1: Identify key stakeholders and end-users

You should already have identified key stakeholders in Stage 1 of this design and development process. You now need to map out the end-users of your decision support tool. To focus the development process, it can be helpful to segment these into your primary target users and secondary users.

Step 2: Capture requirements

In this step, you want to ask representatives of your key stakeholders and end-users about their requirements for the decision support tool. Key issues you will want to cover include:

Their view on purpose and benefits of the tool.
What is the core problem or issue the decision support tool needs to address?
When and where will it be used? For example, will it be used in the community, in ward settings, alongside the patient/service user care record? Will it be used before, during or after consultation with patients or service users?
What will be the trigger(s) for use of the tool?
How will it be accessed? For example, through web or mobile devices, integrated with care record systems.
What information should it offer to help them make their decision?

User research methods

Here are some pointers to user research techniques that you can use to capture requirements. The UK government website on user research provides more in-depth information.

1. Hold one to one interviews

Interview representatives of each key stakeholder and end-user group individually. This technique will help you gather specific requirements.

2. Use focus groups

Conduct group interviews or group workshops to understand the flow of information between different stakeholders and end-users. This technique will help ensure that there will be no conflict of interest later on during the project.

3. Create use cases

Use cases describe specific situations in which the decision support tool would be used by particular end-users. They provide a step-by-step walk-through of use of the tool through the eyes of the end-user. This technique will help visualize how the product will actually work.

4. Build prototypes

A prototype provides users with a mock-up of the look and feel of the final product. You can use PowerPoint slides or hand drawings or create test-bed areas within the Right Decision Service platform to create prototypes. This technique will help address feasibility issues and identify problems ahead of time.

You can use an iterative process to develop progressively more complete prototypes for users to try out, ideally in a real work setting. Jakob Nielsen’s comprehensive online resource provides further information.

Integrate the decision support tool into workflow or care pathway.

Decision support that integrates seamlesley with existing workflow with minimal disruption is most likely to gain ready user acceptance. Sometimes a change in workflow or service model is essential and brings overall benefits to patients and the system. This requires a greater change management effort, and the mapping process outlined below will help in identifying the changes required.

Key stages in integrating decision support into existing workflow or pathways include:

Map out the current care process, workflow or patient/service user journey.
Identify stages where decision support intervention can potentially be useful.
Select the appropriate type of RDS decision support for that stage in the pathway – table 3 below provides some suggestions.
Engage stakeholders in identifying any ways in which decision support may impact on current processes and may require innovative new approaches.

Table 3: Examples of stages in a care pathway, and some types of decision support that may be appropriate to each

Stage in care pathway	Types of decision support that may be of use
Prior to engaging with health and care services	Web or mobile apps for self-assessment, risk assessment or prevention, and self-management (self-management tools may be useful throughout the care journey.)
Initial interaction with a service	Person-specific prompts and alerts embedded in the care record. Shared decision-making apps for professionals and citizens to support and learn from each other. Bidirectional text messaging to prompt engagement and action by the patient / service user. Citizen-facing questionnaires to gather information that can be shared with practitioners. Guidance delivered as web and mobile apps. Links to guidance within the care record (includes the potential for guidance to include links to national and local guidance and to reference sources such as BNF, BMJ Best Practice etc.).
History, assessment	Risk assessment tools or risk prediction calculators Diagnostic prediction tools May be delivered via web or downloadable app or linked to individual’s care record.
Selecting diagnostic tests	Web and mobile apps delivering local and national guidance. Tools embedded in electronic care record that respond to patient details at point of test ordering. Risk prediction calculators. Right Decision Service question and answer tool – creates algorithms in the form of question and answer sequences to guide user through a decision tree.
Selecting interventions	Shared decision aids delivered as web and mobile apps. Guidance delivered as web and mobile apps or linked to individual care record. Right Decision Service question and answer tool – creates algorithms in the form of question and answer sequences to guide user through a decision tree. Risk prediction calculators. Drug interaction or dosage calculators. Alerts and prompts in the care record at point of opening the patient record, point of prescribing or other key decision or action points, eg. referral or escalation.
Follow-up appointments and communication	Patient Reported Outcome and Patient Reported Experience questionnaires embedded in web and mobile apps. Shared decision aids. National and local guidance as web and mobile apps or linked to patient record. Calculators. Right Decision Service question and answer tool – creates algorithms in the form of question and answer sequences to guide user through a decision tree. Risk prediction calculators. Drug dosage calculators. Evidence-based alerts and prompts in the care record at point of opening record or at point of action, eg. prescribing, referral.

Note that sometimes decision support tools may be used not only for supporting care decisions but also to support different tasks, for example to audit records against a clinical standard, or for education. In such cases, you can apply the same processes to map out the audit process or education pathway to ensure the RDS is of use.

Select the appropriate type of decision support tool from Right Decision Service suite

The suite of knowledge translation tools within the Right Decision Service platform enables you to create different types of decision support – see Table 4:

Table 4: Types of decision support included within the RDS and examples of when to use them.

Type of RDS decision support tool

When to use this - examples

1. Narrative content, with embedded images and other media, delivered as web and mobile apps.

Content can be structured, segmented, summarised and organised into decision-ready format for quick and easy retrieval at point of care.

Delivery of guidance, standards, narrative pathways, educational resources, self-management and shared decision-making resources, as web and mobile solutions.

2. Visual pathways (flowcharts)

Nodes in pathways can be opened up to provide further information, links to guidelines, patient information etc.
Pathways are mobile optimised, can be pinched and zoomed, and are fully integrated into the web or mobile app.

Clinical pathways, care pathways, decision trees, flowcharts describing sequences of tasks and processes, patient/service user journeys, providing a summary picture of a whole process of care and support.

3. Question and answer (Q and A) builder

Translates pathways and other types of algorithms into question-and-answer sequences which guide the user through the process to arrive at the appropriate outcome or recommendation for action.
The user can save a text file or PDF report of the output from the tool, including a record of all their responses to individual questions.

Guide user through any form of logical step by step process, for example:

Symptom assessment and checking

Directing end-users to specific resources relevant to their needs
Matching correct referral route or treatment recommendation appropriate to individual needs or criteria
“Check your knowledge” multiple choice quizzes for educational purposes

The Q and A builder can be an alternative way of presenting a visual pathway or website navigation. It is especially useful for complex pathways where there is a risk of the user getting lost in trying to follow the appropriate route.

4. Simple scoring tool builder

Applies the question-and-answer tool to validated evidence-based algorithmic scoring tools. Associates’ responses to questions, which can be summed to provide a final score, usually indicative of risk level. The score can then be associated with recommendations for action.
The user can save a text file or PDF report of the output from the scoring tool, including a record of all their responses to individual questions.

Use for simple calculators and risk scoring tools that rely on addition of values – for example, NEWS2 score, 4AT delirium screening, CHADSVASC score, Geneva score.

MHRA guidance indicates that simple scoring tools of this nature, where the score can be easily checked manually, are not normally considered to be regulated medical devices. However, you should seek advice from the RDS team on the patient safety principles to follow in designing and testing such tools.

5. Forms and reports

You can create a form with free text fields and associate it with predefined question and answer sequences. The form can be saved as a PDF report which the end-user can then save, email, or print.
You can also embed forms created in Microsoft Office or other platforms within Right Decision Service apps and websites.

Creation of workbooks, SBAR and similar reports, data collection.

Note that if you choose to use these forms to include person-identifiable information, you will need to comply with your organisation’s information governance procedures.

6. Integration of algorithms, prompts, alerts and pathways into electronic care record systems.

The Right Decision Service decision support platform provides interfaces to enable integration of algorithms with electronic care record systems.

This may be limited by the quality of structured data within the care record and by the interfaces the care record system provides.

You should discuss this requirement with the Right Decision Service team.